Patient gets hearing on exclusion in hospital network

CONCORD, N.H. (AP) — A Rochester woman will get a hearing after all on her hospital's exclusion from the narrow provider network for individuals buying health insurance under the Affordable Care Act.

CONCORD, N.H. (AP) — A Rochester woman will get a hearing after all on her hospital's exclusion from the narrow provider network for individuals buying health insurance under the Affordable Care Act.

State Insurance Commissioner Roger Sevigny agreed Wednesday to hear a complaint from Margaret McCarthy, a patient at one of the 10 hospitals that were excluded from Anthem Blue Cross and Blue Shield's new network. Anthem had argued that McCarthy waited too long to ask for a hearing, but Sevigny said her request came less than 30 days after she found out how she would be affected by the new network and scheduled the hearing for May 14.

Anthem is the only company selling health plans through the new marketplace created by President Barack Obama's health care overhaul law, though two more plan to join next year. Though its network has been criticized, Anthem officials have said that including all hospitals would have driven up premiums because network hospitals agreed to reimbursement rate concessions in exchange for the promise of a certain volume of patients. Officials at McCarthy's hometown hospital, Frisbie Memorial, have countered that they would have been willing to accept low reimbursement rates but weren't even given a chance to negotiate.

McCarthy purchased her Anthem plan outside the marketplace, before the new network was created, and can keep it until it expires in August. Then, she'll have to decide whether to purchase a new Anthem plan and find new doctors or, as she said earlier this year, "cross my fingers and hope something changes" for 2015.

Anthem had argued that McCarthy knew by mid-September that if she decided to buy insurance through the marketplace that she would have to switch doctors, making her Nov. 6 request for a hearing too late. But Sevigny said the 30-day window to request a hearing didn't start until Oct. 9, when she was able to access information about the plans and subsidies available to her.

"To find otherwise would be to require that an individual file an appeal even before the individual knows whether the act complained of results in an injury," he said.

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